心肾联合移植1例

One case report of combined heart-kidney transplantation

目的 总结心肾联合移植治疗终末期扩张性心肌病合并肾功能衰竭的经验和教训。方法 患者男性 ,5 3岁。入院诊断 :①扩张性心肌病 ,心功能Ⅳ级。②肾功能不全。③糖尿病。供体男性 ,2 8岁 ,脑外伤后脑死亡患者。ABO血型配合 ,淋巴细胞毒试验阴性。 2 0 0 0年 6月 2 6日在全麻中低温体外循环下行标准法原位心脏移植术 ,术中出现肾功能衰竭 ;心脏移植术后 6h行肾移植术。结果 术后心肾功能恢复良好 ,彩色多谱勒超声动态检查 :供肾血流灌注良好 ;供心FS 39～ 5 8% ,EF5 5 73 %。术后 72h发生心脏急性排斥反应 ,以ATG 2 0 0mg/d、甲基强地松龙 1.0g/d冲击治疗 2d后好转。术后 15d再次发生供心供肾急性排斥反应 ,导致心脏肾脏破裂 ,急性心包填塞。经心包引流术和肾周血肿清除引流术并ATG 2 0 0mg/d、甲基强地松龙 1.0g/d冲击治疗后好转。术后 2 5d出现肺部感染 ,30d呼吸衰竭 ,治疗无效于术后 38d死于绿脓杆菌性脓毒血症。结论 心肾联合移植是挽救终末期心脏病合并肾功能衰竭病人生命的有效方法。

Objective To report our experience of one case of combined heart kidney transplantation from same donor. Methods The candidate for transplantation was a 53 year old man with dilated cardiomyopathy and renal dysfunction. Donors were selected on the basis of weight and size match, ABO compatibility, and negative T cell cross match. The heart was grafted by using the standard surgical techniques described by Lower and Shumway, followed by renal transplantation 6 h later. Results Heart and kidney function recovered quickly after operation. The patient had a well functioning heart (left ventricular ejection fraction 55%-73% and left ventricular fractional shortening 39%-58%) and improving function of kidney indicated by continuous decrease of creatinine in plasma at early postoperative stage. Acute rejection episode of heart 72 h after transplantation was reversed with ATG 200 mg/d and Methylprednisolone 1 000 mg/d for 2 d. In 15 d postoperatively, re operation was performed to relieve pericardial tamponade and perirenal hematoma resulted from acute rejection of the heart and kidney. The patient recovered quickly. While, lung infection episode in 25 d resulted in respiratory failure and the patient died from pyemia of pseudomonas. Conclusion Combined heart kidney transplantation from the same donor is an effective method for patients with end stage heart disease and renal failure. It is crucial to resolve the conflict of the postoperative demands between heart and kidney and to keep the balance between immunosuppression and infection control.